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In 1847, Ignal Semmelweis, the “Father of hand hygiene,” discovered the relationship between hand washing and a lower mortality rate in the maternity wards at Vienna General Hospital. Today, his research has proven that hand hygiene contributes significantly to keeping patients safe, demonstrating that clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings. According to the Centers for Disease Control and Prevention (CDC), approximately 1 out of every 20 hospitalized patients in the US contract a healthcare-associated infection (HAI) – a total of 1.7 million HAIs annually – resulting in 99,000 deaths per year with an estimated economic impact of $9.8 billion (USD).In this issue, we are bringing you an exclusive interview with Didier Pittet, MD, MS, who is leading the World Health Organization (WHO) “Clean Care is Safer Care” campaign in more than 180 United Nations member states. The WHO launched their First Global Patient Safety Challenge “Clean Care is Safer Care” in October 2005 to tackle the problem of health care-associated infection (HAI) worldwide, with hand hygiene promotion as the cornerstone.We have a detailed array of articles that will help you understand the impact of hand hygiene and HAIs on patient safety.

Clean HandsThe Dirty Truth About Caring Hands - 100,000 Preventable US Healthcare Deaths PerYearFull, in-depth interview by The SafeCare Group CEO & Chairman Yisrael M. Safeek, MD, MBA with Didier Pittet, MD, MS on leading the WHO Clean Care is Safer Care campaign in more than 180 United Nations member countries, with 5 million lives saved every year. ​​​Yisrael Safeek:Welcome Dr. Pittet. Since 2005 you are the Lead Adviser of the WHO First Global Patient Safety Challenge: Clean Care is Safer Care, currently active in more than 180 of the 194 United Nations member states. Your crusade to eliminate healthcare-associated infections is the subject of the book, Clean Hands Save Lives, edited by l'Age d'Homme and available in 14 languages. You are also featured in the movie "Clean Hands," a special selection of the International Film Festival on Human Rights. Is hand hygiene the primary step to reducing healthcare-associated infections?Didier Pittet:Yes. Absolutely. Of course, hand hygiene is the primary step to reduce healthcare-associated infections in hospitals, but also in healthcare settings all over the world wherever be the hospitals. Once you improve hand hygiene significantly, you observe, 50 percent reduction of healthcare-associated infections. And once again, this is absolutely universal. I have seen results of a successful implementation strategy in hospitals all over the world including the most advanced healthcare systems in the United States, in Australia, or in Switzerland or in Hong Kong as well as in hospitals in much more modest areas.YS: Everyone knows hand hygiene is important, but yet there is a gap between actual practice and what people know is important. Why such a simple measure is not widely performed in the hospitals?DP: You're absolutely right. There is typically a huge gap between the importance and the awareness of the significance of hand hygiene and a poor practice that we record in many hospitals around the world. The most important reason is most healthcare professionals have a totally incorrect estimate of their own performance with hand hygiene practices. Before we started to actually raise awareness about this problem, we would easily find healthcare workers who would tell us that their performance is 80 to 90 percent of the time with hand hygiene practices. While in fact, when we monitored them, we would observe that they were compliant with 10 to 20 percent, max 30 percent, of the time that needed to actually clean their hands.YS: Every healthcare professional gets up in the morning – nurses, doctors want to do what is right every day. What are the main barriers to consistently following recommended hand hygiene practices?DP: There are many barriers. We cannot summarize all the barriers, but there are barriers that one typically thinks that healthcare workers can hardly fight against…like if in your hospital you only have soap and water as an agent to clean your hands. Today it looks very simple, but 20 years ago when we started to say that we had to replace soap and water hand washing by the use of alcohol-based hand rubbing, people were just not following this idea. The reason why we made this system change was we realized, after monitoring HCW washing their hands, that it just took too much time if they wanted to meet compliance. And that was the major breakthrough when we actually said we needed to switch to alcohol-based hand rubbing. Nowadays in the large majority of hospitals around the world, alcohol-based hand rub is available. In some places we call them hand gels, in other hospitals hand sanitizers. Now, the next barrier really to understand is that it is not enough to place alcohol-based hand rub everywhere in the hospital. You need to educate the healthcare workers about the real time and the real opportunity for them to clean their hands. We demonstrated that by research. And these are the so-called ‘My Five Moments for Hand Hygiene,’ which are before patients contact, immediately before any aseptic procedure, after risk of body fluid exposure, after contact with the patient, and, finally, after contact with the surroundings of the patient, even if you have’nt touch the patient.YS: What needs to be done to improve compliance and make it a routine practice?DP: The first element is to make sure alcohol is available everywhere. But when I say everywhere - it is everywhere at the point of patient care. Which means within an arm reach to of the place where you are taking care of the patient. It doesn’t mean in the corridor of the room before contacting the patient. It really means in the room where the patient is taken care off. The second element is to make sure that education of healthcare workers is in line with ‘The Five Moments for Hand Hygiene’…being educated, being recorded, being monitored. The third element is performance feedback. Remember what we said earlier? Healthcare workers have a poor idea of their own performance. You need to come to them with their real performance when taking care of the patient by direct monitoring and then give them relevant feedback. The next element that we developed is actually reminders in the work place about the importance of hand hygiene, the importance of healthcare-associated infection, the importance of resistance to change. And last but not least, the fifth element: having a clear institutional safety climate. If your institution has not developed a strategy with this five elements to make sure that you would change your practice at the point of care, it doesn’t work. Once you have been through this five mode multi-modal strategy, developed by the World Health Organization, once it's implemented in the institution, only then you will see by using the tools and the implementation strategy that behavior will change.YS: One of the observations that we've seen is that several time hospitals claim a 100 percent compliance, only to hear about them having hospital acquired infections. Is the 100 percent compliance realistic?DP: No, clearly not. Hospitals claiming 100 percent compliance are either lying or don’t know how to monitor compliance which is probably the case most of the time. When we are talking about compliance with hand hygiene we are not talking only before entry in a room and after room exit. We are talking about real compliance monitoring at the bedside while healthcare workers are taking care of patients. 100 percent compliance as an average in a hospital, I’ve never seen, and I have visited more than 2,000 hospitals all around the world. Even the best hospitals hardly reach a 90 percent compliance on average. The good news is that you don’t need 100 percent compliance – when you improve compliance from 30, 40 percent to 60 percent, it reduces infections; when you improve compliance from 65 percent to 75 percent it's further reduces infection rates and so on.YS: Okay, hand hygiene campaigns tend to improve compliance temporarily, and after some initial success they undergo campaign fatigue. How can compliance become more permanent? Please elaborate on "I provide," "I promote," or "I deserve."DP: Yes, I can elaborate with a very concrete example. Campaign fatigue is already coming in your institution once you have been successful for like three, four years, and can it be a danger. It's not always the case. Now, once you are there you actually need to find creative ways to still have your healthcare workers promoting hand hygiene. Last year, a hospital in Hong Kong, recognized in 2012 as Hand Hygiene Excellence institution by WHO, invented the hand sanitizing relay: having as many healthcare workers as possible passing the alcohol-based hand rub from one hand to another, setting a new Guinness World Record. I can tell you that this is quite a challenge. In 2015, we had more than 30,000 people on the five continents trying to establish a new Guinness World Record. And this was a way to fight campaign fatigue. But I would say you cannot speak of campaign fatigue unless you have really fully endorsed, understood and implemented the five mode multi-modal strategy of the WHO. Now speaking of I provide, I promote, I deserve and I could also add, I demand. This is what we launched last year at WHO on the occasion of 5 May 2015. May 5 is celebrated every year worldwide as the WHO Hand Hygiene Day. This #safeHANDS campaign was endorsed by 60 million people around the world in three months. I don’t know of many campaigns reaching 60 million healthcare workers. ‘I provide’ was to say that a healthcare worker must provide clean hands or safe hands. Then ‘I promote’ means I can promote Safe Hands which means Clean Hands that are Safe Hands. The Clean Care is Safer Care campaign is saving between five and eight million lives every year in the world. Now last but not the least ‘I deserve’ means that as a patient I deserve Clean Hands, which means I deserve Safe Hands. Finally, ‘I demand’ Clean Hands, means that as a family member, relative of friend, I demand Safe Hands for patients seeking health care.YS: Deemed hospital inspections in the U.S. give hospitals a choice between the WHO and CDC guidelines. Why should a hospital implement the WHO guidelines? DP: Actually the WHO hand hygiene guidelines have been endorsed by the CDC. So, it doesn’t make so much of a difference if you like, in that respect. The difference between the two is that the WHO guidelines are associated with an implementation strategy: the five element multi-modals strategy together with the tool kits that have been developed for people to apply the guidelines. The CDC guidelines have no tools associated to them, there is no implementation strategy to drive the institution toward success. That’s why we recommend hospitals to have a look at the implementation strategy we developed at the WHO and that’s why we recommend these to be used all over the world. One more difference is that the WHO guidelines have been tested and validated all over the world in pilot centers and results published in the peer-reviewed literature. Among those pilot centers, were pilot centers in the U.S.YS: Among the multi-modal hand hygiene improvement strategy, which element is the most effective to improve compliance? DP: Well none of them is more effective than another. Because by definition that’s a multi-modal strategy, so you have to implement all the elements to get the full power of the strategy. Installing alcohol at the bedside doesn’t change anything if you don’t have the support of the multi-modal strategy with education, reminders, surveillance, feedback and institutional safety culture. And that’s absolutely key, so you need the five elements for a full and complete success and more than these you also need to adapt the strategy to your institution in many circumstances. It's always better to use your posters that have been designed by your own people, and not posters that may have been designed by people outside of the institution. So, it is what we call – and this is very, very important – this is what we call “adapt to adopt”. Let healthcare workers adapt the strategy to the own institution, they own needs in order for the strategy to be largely adopted. Let people make the promotion of their own success. YS: Is there a Hawthorne Effect in Hand Hygiene Compliance Monitoring? Which works best – direct, in-person observation, or indirect, remote monitoring? DP: Well in fact, even in the state of current technology, direct monitoring is still the best, reliable monitoring technique. Remote monitoring is not possible for all situations and does not allow you to tell if people are really cleansing their hands at the right appropriate time. So of course when you monitor directly there is a Hawthorne Effect. We all know that: if the police are watching me, I will fasten my seatbelt immediately provided I forgot to fasten my seatbelt. So, all of these is of course expected. YS: What about RFID-linked technology, is there a role for it in hand hygiene compliance? DP:I can tell you there is not one week where I do not receive proposals from many companies - large companies or small startups. Tods like that are coming with all sorts of technologies to monitor hand hygiene compliance. And among them RFID linked technology. The technology is interesting, but still in its infancy. For sure on the long-term, automatic monitoring would allow to reduce the workload of those monitoring compliance directly. It would be very, very exciting, but unless the technology is perfect or almost perfect. There is still a long way to go and today it's not that we are closed to almost perfect, it's that we are far away from perfect. YS: Here in the U.S. several hospitals utilize a program called Speak Up. Should such programs empower patients to alert caregivers to perform hand hygiene? DP: Yah, speak up programs can be called patient empowerment, patient participation - there are several names for the same idea. It's very common all over the world. It has been tested scientifically in many places like in Australia, in Saudi Arabia, in the U.K., in Switzerland, in Hong Kong even in resource-limited countries like Vietnam. We tested it in Africa also. It’s still a very important perspective to involve patients, to actually remind healthcare workers to clean their hands. But I can tell you we have tested it in cluster randomized controlled studies. It works, but it's not that easy. Forget about using Speak Up in a hospital where the five mode multi-modal strategy as proposed by WHO is not really and formally established. Why?​ Let’s imagine the scenario: if you, as a healthcare worker, are coming to a patient and the patient is reminding you to clean your hands. And then (A) you don’t have any alcohol-based handrub available within an arm-reach. (B) You go to the dispenser, but the dispenser is empty. (C) You don’t remember the five moments. (D) You don’t know exactly about when you have to do it. (E) There's no institutional site-safety efforts behind you. You have a lot of chances to not perform well, and then there will be trouble in the relationship between you, the healthcare worker, and the patient. Last but not the least, there are many, many patients that are incapable of reminding caregivers. Think about patients intubated in the ICU. Think about demented patients. Think about very young children. I can give you many more examples. What I can tell you is that you have to implement a successful strategy at your institution based on the multi-modal strategy that we developed for WHO, and then you can start with the patients speak up or the patient participation or the patient empowering program. And then it raises your compliance level to the next level. YS: Should caregivers be penalized for not performing hand hygiene or is respectful engagement more effective?DP: Well personally, I'm against punishment. Most of the time, I think you have to be much more respectful with the healthcare workers and get them engaged in your strategy, developing tools to fight campaign fatigue, to adapt the strategy, so that the strategy would be adopted in your institution. You know, there is so much to do before punishment that I'm personally against it. When hospitals witness their progress, months after months, years after years, they are rewarded and then you don’t need punishment anymore. YS: Can surgeons utilized alcohol-based hand rub?DP:Absolutely. If you'll go through the WHO guidelines very carefully, there is an entire chapter about it. It's very commonly used in all over the world. The advantage of alcohol-based hand rub used for surgical hand preparation, it's a little bit faster, and it’s much better tolerated for your hands. It's actually more powerful on bacteria even when you test the hands after several hours below the gloves of the surgical team. And in addition, it is very, very interesting in many places around the world, where water is missing. Like currently in Brazil, they have problem with water. Surgeons use between 16 and 22 liters of water to prepare their hands for surgery. You multiply these by at least two, three people and you immediately get the large amount of water that is actually lost for preparing the hands of the surgical team for surgery. So that's another very important element for the surgical hand preparation using alcohol-based hand rub. YS: Should patient visitors entering a patient's room perform hand hygiene? DP: For visitors, it’s clear that we are lacking good science. The WHO guidelines have been developed based on the evidence. Now, there's not so much evidence of the benefit of visitors rubbing their hands before entering a room but we have some case reports of some accident. It's probably important that we can easily demonstrate these at time of flu, just reduce the level of cross transmission by cleaning their hands and probably sometimes wearing a mask. That’s what we do in our institution: we recommend patients to tell their visitors to clean their hands upon room entry and room exit. Room entry to protect the patients and the environment, and room exit to protect the next environment that they will be in contact with.YS: Will over-use of alcohol-based handrubs result in antimicrobial resistance? DP: No, in fact the good news are that there is no resistance to alcohol because the mechanism of action of alcohol is totally non-specific. So, it just made the wall of the viruses and the bacteria explode. So, in contrast to medicated soap, antiseptics, antibiotics and anti-viral drugs, there is no resistance to alcohol. So, that’s really very, very powerful and remember, once you have used alcohol on your hands, then the bacteria are killed, and the alcohol evaporates.YS: What’s your most challenging “adapt to adopt” situation to date? DP: (Laughs) That’s an interesting part, we have had many different challenges - the most important was certainly to get the Muslim healthcare workers to actually accept the use of alcohol for their daily practice in patient care. You and I perfectly know that Muslims cannot drink alcohol, but what I didn’t know was that the Koran is a lot more complicated about this issue. In fact, Muslim healthcare workers, and Muslims in general, cannot absorb any alcohol whatever - be the minimal, the quantity that you could absorb, either by sneezing or by actually spraying your hands with alcohol. So we had to actually solve this by visiting the Muslim League in Saudi Arabia, and we obtained a fatwa. And today, alcohol used by Muslim healthcare workers in Muslim countries is one of the largest recorded all around the world. That is really telling us that we have been successful adapting the situation in order for the healthcare workers to adopt the strategy.YS: In all your years working on hand hygiene, what has surprised you most?DP: Well the importance of the cultural diversity and the example I gave you here with the Muslim healthcare workers and the use of alcohol is certainly very interesting. But there are many others. I realized that in Indian culture, when you draw an arrow to explain how you should clean your hands, you should always go clockwise and never counter clockwise. These are minor things but these are key things for cultural diversity. And, when I visit hospitals all around the world, I am still surprised in many ways. You know, when I visited the largest hospital, Mother and Child Hospital of Indonesia, where they perform 55,000 deliveries a year. Can you imagine what it means? Fifty five thousand deliveries every year. When I saw the campaign activity with three years where we monitored infections and then we implemented the strategy. And after five years, implementing the multi-modal strategy from WHO, infections had been reduced by 80 percent in mothers and children and we also saw a reduction in mortality of 80 percent. When you see that on the large scale, it's quite an emotion. Finally, what probably surprised me the most was the importance of health diplomacy. Health diplomacy is meeting with Health Ministers all around the world and tell them about the importance of hand hygiene, healthcare-associated infection and how changing the behavior of healthcare professionals could really save many lives. You know you can use the most advanced technique in organ transplant and lose your patient from a stupid healthcare-associated infection that was only related to the fact that healthcare workers forget to clean their hands. The most advanced system is not protected from a basic behavior gesture. That to me was really one of the most important and interesting lessons over the past 20 years.YS:Dr. Pittet, on behalf of The SafeCare Group, I want to thank you for devoting your efforts so that all of mankind can benefit from Clean Care is Safer Care.

The risk of acquiring Healthcare Associated Infections (HAI) pervades every healthcare facility, and caregivers are often the conduit for the spread of such infections. The CDC stated in its National and State Healthcare-Associated Infections Progress Report (2014 data, published 2016) that HAI continues to account for complications in one in 25 hospitalized US patients, and they are costly, deadly, and largely preventable. During 2011, an estimated 722,000 HAI occurred in US acute care hospitals, and approximately 75,000 patients with HAI died during hospitalization, making HAI among the top 10 leading causes of death in the US. More than half of all HAIs occurred outside of the intensive care unit.​ Applying two different Consumer Price Index (CPI) adjustments to account for the rate of inflation in hospital resource prices, the overall annual direct medical costs of HAI to U.S. hospitals ranges from $28.4 to $33.8 billion (after adjusting to 2007 dollars using the CPI for all urban consumers) and $35.7 billion to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services).

Infectious diseases are a particular risk to the very young, the elderly, those with a preexisting disease, and people with a compromised immune system. Nurses washing their hands not only prevent them from getting sick, but it also reduces the risk of infecting others. Infections associated with healthcare has been targeted by the World Alliance for Patient Safety during the first biennial Global Patient Safety Challenge, ‘Clean Care is Safer Care’ compliance to hand hygiene is widely acknowledged as the most important way of reducing infections in healthcare facilities and the spread of antimicrobial resistance. In the USA, serious nosocomial infections cause 99,000 patient deaths per year. Research has shown that while healthcare workers state largely favorable attitudes towards hand cleaning practices, observed compliance rates are below 30%. In Europe, the estimated five million Hospital-acquired infections (HAIs) that occur annually have an assumed attributable mortality of 50,000 to 135,000 at a cost of €13 to €24 billion. Adequate hand hygiene among hospital personnel could prevent an estimated 15% to 30% of the HAIs.

The World Health Organization (WHO) Multimodal Hand Hygiene Improvement Strategy comprising a Guide to Implementation and a range of tools constructed to facilitate implementation of each component was used in a 1600-bedded acute tertiary care general hospital in Singapore. 1 The objective is to change healthcare workers’ behavior and improve hand hygiene compliance. During the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, a high compliance of close to 90% in healthcare workers to hand hygiene was achieved. However, this was primarily driven by fear for transmission of pathogens to self. Following the closure of the SARS outbreak globally, we noted that the hand hygiene compliance decreased to that of the baseline before the SARS outbreak i.e. the high hand hygiene compliance was not sustainable. The hand hygiene program was revised in early 2007 following Singapore’s signing of the pledge to the WHO “Clean Care is Safer Care” program. The multi-prong approach used includes:System change:a. Alcohol based hand rub was promoted for routine use of hand hygiene instead of the previous 4% chlorhexidine hand wash. During SARS, alcohol hand rub bottles were installed at the foot of every patient bed and all lift lobbies in an attempt to enable easy access by healthcare workers to hand hygiene products. From 2007, more alcohol hand rub bottles were installed along ward corridors and near food establishments in the hospital ground. b. Following the review of the WHO Hand Hygiene Manual (Advanced Draft 2006), 2 the Infection Control Committee approved the use of at least either ethanol 80% or isopropyl alcohol 75% in the procurement of hand hygiene alcohol hand products. This implies the use of a higher content of alcohol than before. From July 2009, 4% chlorhexidine hand wash agent bottles were removed from the clinical areas except for the Operating Theaters, Endoscopy Unit and Treatment rooms. This was done to reduce the incidence of dryness or skin irritation resulting from concomitant use of both alcohol and chlorhexidine. 1 Hand moisturizer was provided freely for healthcare workers’ use. They are encouraged to use it as often as possible to protect their hands. Training & education:Training & education:a. WHO training DVDs were used to illustrate clinical scenarios of hand hygiene opportunities to all healthcare workers. Although these were in French, they provided clear teaching on the 5 moments to the staffs.b. Creative educational tools were also used to teach healthcare attendants and junior nurses. Teddy bears dusted with Glo-germ were used as patient models in teaching healthcare workers the importance of hand hygiene as well as the WHO 5 moments.c. PowerPoint slides with detailed explanation of the 5 moments were created for doctors, nurses and allied health. These were uploaded on the hospital intranet for easy access by the staffs.Evaluation and feedback:Feedback surveys are conducted annually amongst staffs to gather feedback and comments on products used or issues faced during practice. The last survey done in November 2010 confirmed that the use of posters have helped to remind staffs and public on the messages of hand hygiene.Reminders in the workplace:More than 150 posters were designed from March 2007 for display at elevators and walkways. Giant posters on hand hygiene messaging (spanning nine floors) were designed to convey the hospital’s commitment to the public. Shuttle buses, floor surfaces and lift doors are used to display reminders to both staffs and public.Institutional safety climate: Leadership’s support and commitment was clearly visible at events and meetings. The Chief Executive Officer (CEO) led the hospitals staffs in November 2009 in a pledge of commitment to the Hand Hygiene Program. Hand hygiene compliance rate improved from 20% (in January 2007) to 61% (2010). Improvement was also seen annually in the compliance to each of the 5 moments as well as in all staff categories. Although hand hygiene compliance was lowest in the doctors’ category, it is encouraging to note that improvement was also seen year to year in this job category. The hand hygiene program was an integral part also of an ongoing MRSA reduction program in the hospital, which includes the implementation of the MRSA bundle.

The “MRSA bundle” includes five components of care. This bundle was first introduced by the Institute of Healthcare Improvement (IHI) in 2006 in their “Protecting 5 Million Lives from Harm” campaign. It comprised the following elements: 1. Hand Hygiene2. Decontamination of the environment/equipment3. Active surveillance cultures4. Contact precautions for infected and colonized patients5. Device bundles (CLABSI, CAUTI, and VAT bundles) Most of the elements were routine practices in the hospital except for active surveillance cultures, which were implemented hospital-wide for high risk patient groups from 2008. Healthcare-associated MRSA infections were noted to reduce from 0.6 (2007) to 0.3 (2010) per 1000 patient-days. Leadership’s support of the program evidenced through visible leadership presence, messaging and release of resources is the key factor in helping to make the program a true success. The hospital was recognized as a Global Hand Hygiene Expert Center in January 2011. The use of the WHO multi-prong interventions is successful in improving hand hygiene compliance with concomitant reduction in healthcare associated infections.